Fluid jet tissue resection and cold coagulation methods

ABSTRACT

An apparatus is configured to provide hemostasis with tissue removal in order to inhibit one or more of blood loss or tissue drainage. In many embodiments, a nozzle releases a liquid jet in a liquid medium in order to provide cavitation and a plurality of shedding pulses. The liquid jet, its cavitation and the plurality of shedding pulses can affect vascular tissue in order to promote clotting in order to inhibit bleeding. In many embodiments, vessels of the vascular tissue are affected at a distance from a region where cavitation of the water jet contacts the tissue. In many embodiments, the cavitation and plurality of shedding pules are related to a pulsatile shear wave propagating along the blood vessel that is related to clot promoting changes of the blood vessel.

RELATED APPLICATIONS

The present application is a divisional of U.S. patent application Ser.No. 15/388,515, filed Dec. 22, 2016, which is a continuation ofInternational Application No. PCT/US2015/038605, filed Jun. 30, 2015,published as WO 2016/004071 on Jan. 7, 2016, which claims priority toU.S. Provisional Application No. 62/019,299, filed Jun. 30, 2014, andU.S. Provisional Application No. 62/032,958, filed Aug. 4, 2014, theentire disclosures of which are incorporated herein by reference.

The subject matter of this international application is related to andincorporates by references the complete disclosures of the followingU.S. patents and applications: U.S. Provisional Application No.61/874,849, filed Sep. 6, 2013, entitled “AUTOMATED IMAGE-GUIDED TISSUERESECTION AND TREATMENT,” U.S. Provisional Application No. 61/972,730,filed Mar. 31, 2014, entitled “AUTOMATED IMAGE-GUIDED TISSUE RESECTIONAND TREATMENT,” U.S. Provisional Application No. 62/019,305, filed Jun.30, 2014, entitled “AUTOMATED IMAGE-GUIDED TISSUE RESECTION ANDTREATMENT,” U.S. patent application Ser. No. 12/700,568, filed Feb. 4,2010, entitled “MULTI FLUID TISSUE RESECTION METHODS AND DEVICES,” nowU.S. Pat. No. 9,232,959, issued Jan. 12, 2016.

The subject matter of this international application is also related toInternational Application No. PCT/US2013/028441, filed Feb. 28, 2013,published as WO 2013/130895 on Sep. 6, 2013, entitled “AUTOMATEDIMAGE-GUIDED TISSUE RESECTION AND TREATMENT,” and InternationalApplication No. PCT/US2011/023781, filed Feb. 4, 2011, published as WO2011/097505 on Nov. 8, 2011, entitled “MULTI FLUID TISSUE RESECTIONMETHODS AND DEVICES,” the entire disclosures of which are incorporatedherein by reference.

BACKGROUND

The field of the present invention is related to the treatment oftissue, and more specifically to the surgical treatment of an organ suchas the prostate.

Prior methods and apparatus of incising tissue of subjects such aspatients can result in less than ideal results in at least someinstances. For example, prior methods of prostate surgery can result inlonger healing time and less than ideal outcomes in at least someinstances. In at least some instances, prior methods and apparatus oftissue resection can result in more bleeding than would be ideal. Also,the prior methods and apparatus of cutting tissue can provide lessaccurate cuts than would be ideal. Although electrocautery and lasercoagulation have been proposed as a potential solution to bleeding,treatment with electrocautery or laser coagulation may result in anadditional step to removal of tissue, and the control of bleeding can beless than ideal. Also, the heat associated with electrocautery mayresult in less than ideal results in at least some instances.

With prior surgical procedures, the recovery time of the patient can berelated to the manner in which tissue is removed, and it would behelpful to provide surgical procedures with decreased recovery times.Also, tissue drainage can be somewhat greater than would be ideal andcan be related to the manner in which tissue is incised. In at leastsome instances, patients may benefit from a blood transfusion followingsurgery, and it would be better if fewer blood transfusions wererequired subsequent to surgery.

Although removal of tissue with water jets can result in successfulremoval of tissue, work in relation to embodiments suggests that furtherimprovements may be helpful. For example, the prior methods andapparatus of cutting tissue with a water jet can result in somewhat lessaccurate cutting and potentially more bleeding than would be ideal in atleast some instances. Although prior methods of tissue cutting can cutablate tissue with fluid jet technology with the decreased transfer ofheat to the tissue, work in relation to embodiments suggests that in atleast some instances prior water jet cutting can result in amounts ofbleeding that can be somewhat greater than would be ideal.

In light of the above, it would be helpful to provide improved methodsand apparatus for tissue treatment such as surgery. Ideally such methodswould provide improved resection of tissue with decreased bleeding andimproved outcomes.

SUMMARY

The embodiments provide improved methods and apparatus of cutting tissuewith a water jet. In many embodiments, the apparatus is configured toprovide hemostasis with tissue removal in order to inhibit one or moreof blood loss or tissue drainage. In many embodiments, a nozzle releasesa liquid jet in a liquid medium in order to provide cavitation and aplurality of shedding pulses. The cavitation and the plurality ofshedding pulses can affect vascular tissue in order to promote clottingin order to inhibit bleeding. In many embodiments, vessels of thevascular tissue are affected at a distance from a region wherecavitation of the water jet contacts the tissue. In many embodiments,the cavitation and plurality of shedding pules are related to apulsatile shear wave propagating along the blood vessel that is relatedto clot promoting changes of the blood vessel. In many embodiments, thenozzle is placed at a distance from a tissue removal profile in order toprovide substantially abrasive tissue removal, in which vascular tissueand non-vascular tissue with less collagen are removed at similar rates.Alternatively or in combination, the nozzle can be placed at a distancefrom a tissue removal profile in order to provide substantiallyselective tissue removal, in which vascular tissue and non-vasculartissue with less collagen are removed at substantially different rates.In many embodiments, an endothelial cell lining of the vessel wall isaffected in order to promote blood clotting within the vessel.

In many embodiments wherein bleeding of the vascular tissue is inhibitedwith one or more of: induced thrombosis in capillaries and arteriolesrelated to endothelial injury, shear stress and reduction in blood flow;adhesion and aggregation of platelets; deposition of fibrin; depositionof fibrin related to obstructive vessel clotting; fluid pressure in anaffected zone; fluid pressure in an affected zone at a distance from aremoval profile; inhibited blood the affected vessels; partial collapseof the affected blood vessels; full collapse of the affected bloodvessels; and combinations thereof.

INCORPORATION BY REFERENCE

All patents, applications, and publications referred to and identifiedherein are hereby incorporated by reference in their entirety, and shallbe considered fully incorporated by reference even though referred toelsewhere in the application.

BRIEF DESCRIPTION OF THE DRAWINGS

A better understanding of the features, advantages and principles of thepresent disclosure will be obtained by reference to the followingdetailed description that sets forth illustrative embodiments, and theaccompanying drawings of which:

FIG. 1A is a schematic illustration of a device suitable for treatingtissue in accordance with embodiments;

FIG. 1B shows a computer-controlled device suitable for treating tissuein accordance with embodiments;

FIG. 1C shows a nozzle for treating tissue in accordance withembodiments;

FIG. 2 shows an ablative flame visible to the human eye, in accordancewith embodiments.

FIG. 3 shows a high-speed image of the ablative flame as in FIG. 2 takenat a speed of about 1/400 of a second, in accordance with embodiments;

FIG. 4 shows a plurality of shedding pulses 995 and sweeping of theablative jet to provide smooth and controlled tissue erosion at aplurality of overlapping locations 997 in accordance with embodiments;

FIG. 5 shows maximum tissue penetration depth of cutting and flow ratethrough a nozzle in accordance with embodiments;

FIG. 6 shows maximum tissue penetration versus flow rate similar to FIG.5 in accordance with embodiments;

FIG. 7 shows a threshold transition from selective removal to abrasiveremoval comprising a slope similar to the slope of the maximumpenetration depth, with an offset in accordance with embodiments;

FIGS. 8A and 8B show selective tissue removal, in accordance withembodiments;

FIGS. 9A and 9B show highly abrasive tissue removal in accordance withembodiments;

FIG. 10 shows a collapsed vessel wall, in accordance with embodiments;

FIG. 11A shows a water jet flame removing tissue with shedding pulses inaccordance with embodiments; and

FIG. 11B shows disruption to a blood vessel in accordance withembodiments.

DETAILED DESCRIPTION

A better understanding of the features and advantages of the presentdisclosure will be obtained by reference to the following detaileddescription that sets forth illustrative embodiments, in which theprinciples of embodiments of the invention are utilized, and theaccompanying drawings.

Although the detailed description contains many specifics, these shouldnot be construed as limiting the scope of the invention but merely asillustrating different examples and aspects of the invention. It shouldbe appreciated that the scope of the invention includes otherembodiments not discussed in detail above. Various other modifications,changes and variations which will be apparent to those skilled in theart may be made in the arrangement, operation and details of the methodand apparatus of the present invention disclosed herein withoutdeparting from the spirit and scope of the invention as describedherein.

As used herein the term “AquaBeam” encompasses a liquid jet provided ina liquid to provide cavitation to tissue.

The fluid jet tissue ablation (hereinafter “Aquablation”) and methodsand apparatus for providing hemostasis with tissue cutting as disclosedherein are well suited for combination with many prior surgicalprocedures and apparatus. In many embodiments, improved hemostasis isprovided, which is related to the tissue incision with the jet. In manyembodiments, the jet comprises jet in a liquid medium which inducescavitation of the jet, which can be referred to as a cool flame, whichcan be related to the substantially mechanical shear stress interactionsbetween the high-velocity fluid jet and the vessels in contact with thejet. In many embodiments, the jet comprises sufficient energy above thethreshold of cavitation such that tissue removal of the jet issubstantially insensitive to the type of tissue and amount of collagenof the tissue and can cut vascular and granular tissue at similar rates.The mechanical contact of tissue with the jet and corresponding shearcan induce micro-thrombosis in capillaries and arterioles can provideimproved coagulation and corresponding hemostasis. In many embodiments,the endothelial cells can be affected so as to facilitate the release ofblood clotting factors. The effect to the endothelial cells as describedherein can occur at a distance from the site where the cavitations ofthe jet and liquid medium strike the tissue in order to provide improvedhemostasis. In many embodiments, the substantially mechanical shearstress can provide damage to the endothelial cells and provide areduction in blood flow, and may facilitate and enhance the adhesion andaggregation of platelets and deposition of fibrin, so as to provideobstructive vessel clotting.

In many embodiments, shear stress supplied by the jet is sufficient toinduce platelet aggregation independent of complement activation. Theplatelet aggregation independent of complement activation can occur in amanner similar to areas of high hemodynamic shear, such as in arterialstenosis as described previously. See Blood. Sep. 15, 2006; 108(6):1903-1910. PMCID: PMC1895550 Activation-independent platelet adhesionand aggregation under elevated shear stress. Z M Rugerri et al. Byproviding water jet shear stress directly to affected vessels, for asufficient period of time platelet aggregation may achieve initialhemostasis, allowing the coagulation cascade to thrombose the affectedvessels and achieve lasting hemostasis. As shear increases, the time toachieve hemostatic platelet aggregation may decrease. The Aquablation asdescribed herein can be tuned to improve hemostasis by controlling pumppower (and with it fluid velocity, and shear stress magnitude) and rateof translation of the water jet. In many embodiments, higher pumpingpower and slower translation of the jet are pro-hemostatic.Alternatively or in combination, the relative contribution of varioushemostatic factors (local pressure gradients, shear modulatedhemostasis, cavitation induced thrombosis) can vary depending on theposition of the vessel relative to the jet (for a specific pump power)position, as related to the evolution of the flame with distancetraveled from the jet nozzle exit.

While the vessel clotting can be provided in one or more of many ways,in many embodiments the fluid pressure in the affected zone duringtissue treatment with the water jet may rapidly inhibit andsubstantially decrease blood from exiting the affected vessels. In manyembodiments, the hemostasis as described herein is related to thepartial or full collapse of the affected vessels. In many embodiments,the substantially mechanical shear stress provided with the cavitationscan provides fluid jet tissue resection and ablation of tissue and alsoto heat-free tissue coagulation.

FIG. 1A shows apparatus 100 comprising a handheld device, which maycomprise a shaft 102 having a distal end with a nozzle 104 oriented todeliver a pressurized fluid in an axial stream water jet 101 withcavitation 103 as disclosed herein. The jet and tissue T can be immersedin a liquid L such as saline or another liquid to provide sheddingpulses with cavitation as disclosed herein, for example. The liquid canbe provided over the tissue with a gas G such as air above the liquid.Alternatively or in combination, the tissue may comprise an internaltissue covered with the liquid, for example. Water or other fluid isdelivered under pressure from the nozzle. The handheld device 100 iscapable of delivering an axial water jet or other pressurized fluidstream and is useful for the manual cutting of tissue or bone, forexample. The handheld device 100 is connected to a pressurized fluidsource 120, a fluid flow monitor 122, and control circuitry 124,typically by a connecting cord 126. The fluid flow monitor 122 maycomprise a pressure monitor for example. The user can thus control thefluid pressure, movement of the nozzle (velocity, direction, limits,etc.) and other aspects of the treatment protocol in addition to theaxial and rotational movement parameters using the control circuitry.Optionally, although not illustrated, the nozzle 104 will be adjustablein order to adjust the width and focus of the fluid stream FS in orderto allow further flexibility for the treatment. When used for cuttingtissue, the hand-held shaft can be manipulated much as a scalpel.Alternatively, the nozzle can be mounted on a computer-controlledpositioning system such as a rotating, translating and oscillatingprobe, or a robotic arm, and combinations thereof.

In many embodiments, the pressurized pump comprises a high-pressure pumpsuch as a piston pump, for example. The control circuitry can be coupledto the pressure monitor 122, so as to provide a controlled flow rate.The controlled flow rate, in combination with the nozzle can provide acavitation flame at distance, in order to incise tissue as disclosedherein.

FIG. 1B shows an apparatus 100 comprising computer-controlled devicesuitable for treating tissue T in accordance with embodiments. Apparatus100 may comprise a linkage 130 coupled to the treatment probe in orderto treat tissue in response to computer commands. The linkage maycomprise a linkage capable of translation, or capable of a rotating,oscillating and translating, and combinations thereof, for example. Thelinkage can be coupled to the processor 132 and may be guided under usercontrol, for example. The embodiments disclosed herein are suitable forcombination with many devices to remove tissue, such ascomputer-controlled image guided treatment apparatus incorporated hereinby reference elsewhere.

FIG. 1C shows a nozzle 104 for treating tissue in accordance withembodiments. The nozzle can be configured in one or more of many ways asdescribed herein and is suitable for combination with flow rates inorder to provide tissue removal with hemostasis as described herein. Inmany embodiments, a flow rate through the nozzle and the configurationof the nozzle provide a maximum tissue removal distance. The jet 101from the nozzle may comprise a selective tissue removal region 105 and anon-selective tissue removal region 107. The selective tissue removalregion 105 of the jet can selectively remove tissue at rates in responseto collagen of the tissue. For example, collagenous tissue such as bloodvessel walls can be removed more quickly than tissue with less collagensuch as granular tissue. The non-selective tissue removal region 107 ofthe jet can remove tissue having different amounts of collagen assubstantially similar rates. For example, collagenous tissue such asblood vessel walls can be removed at rates substantially similar totissue with less collagen such as granular tissue. A thresholdtransition zone 109 can be located between the selective tissue removalregion and the non-selective tissue removal region.

The nozzle can be mounted on a carrier 382 comprising a fluid deliveryelement and design considerations of the fluid delivery element. Thecarrier 382 can be provided on a rotating, translating and oscillatingprobe, for example. The jet orifice 111 design of the fluid deliveryelement can be configured in one or more of many ways as describedherein, so as to provide a plurality of shedding pulses. Fluid jetablation characteristics can be varied by varying the jet orificegeometry. For example, cone angle 113 variation can result in anincrease or decrease in cavitation 103 occurring at the nozzle exit. Thejet orifice design may comprise a cone at one or more of the entrance orthe exit of the orifice 111. The cone angle can vary from 0 to 180degrees, for example.

In many embodiments, the jet nozzle profile also influences the degreeof fluid acceleration and amount of cavitation. For example, asharp-edged orifice can induce a higher jet velocity at exit from thevena cava effect, with correspondingly greater amounts of cavitation 103in the jet far field.

The orifice diameter 115 and orifice length 117 variation can result ina variation in nozzle back pressure and exit speed of the fluid stream.The resulting cavitation region varies with each of these parameters.The cavitation region may comprise a cloud of cavitation bubblesgenerated by the nozzle. The depth of tissue penetration can bedetermined and controlled as described herein. In many embodiments thecavitation region can be visualized with ultrasound imaging or opticalimaging in combinations thereof. The cavitation region corresponds to aregion where bubbles are formed, which allows the entrainment region tobe visualized and can be referred to as a fluid flame. The cool cuttingof the cavitation region can allow for tissue removal with minimaltissue damage. In many embodiments the cone angles within a range fromabout 40 degrees to about 80 degrees. A ratio of the orifice length tothe inner diameter of the orifice can be within a range from about 1 to10, for example, within a range from about 4 to 7. A person of ordinaryskill in the art can design a jet orifice to treat tissue as describedherein based on the teachings provided herein.

Cold Flame

FIG. 2 shows an ablative flame visible to the human eye, in accordancewith embodiments.

FIG. 3 shows a high-speed image of the ablative flame as in FIG. 2. Theimage was taken at a speed of about 1/400 of a second.

The data of FIGS. 2 and 3 show that the ablative flame comprises aplurality of white clouds generated with the ablative stream whenreleased from the nozzle. Work in relation to embodiments has shown thatthe cavitating cloud can shed from the jet at a characteristic sheddingfrequency. A length 992 of each cloud is related to the sheddingfrequency and the velocity of the cloud. The relatively cool ablativeflame of the jet comprises a length 990 corresponding to the cuttinglength of the jet which can be adjusted to cut tissue to controlleddepth as described herein. In many embodiments, nozzle of the jet isplaced at least about a quarter of the length 992 of a shed cloud in annon-cutting configuration as shown in FIG. 3, in order to allow theshedding cloud to substantially form prior to the cloud striking tissue.This divergence of the shed cloud to a larger cross-sectional size canalso provide improved tissue removal as the cloud can be distributed toa larger region of tissue and provide improved overlap among the pulsesof the jet.

In addition to the impact pressure of the jet, the highly turbulent andaggressive region corresponding to the white cloud of the imagecontributes substantially to the ablation of tissue as described herein.The white cloud comprises a plurality of cavitation regions. Whenpressurized liquid comprising water is injected into water, smallcavitations are generated in areas of low pressure in the shear layer,near the nozzle exit. The small cavitations may comprise cavitationvortices. The cavitation vortices merge with one another, forming largediscrete cavitation structures that appear in the high speed images ascavitation clouds. These cavitation clouds provide effective ablationwhen interacting with tissue. Without being bound by any particulartheory, it is believed that the cavitation clouds striking tissue causesubstantial erosion of tissue related to the cavitations in combinationwith the high velocity fluid that defines the cavitation clouds strikingtissue.

The nozzle and pressure as described herein can be configured to providethe pulsatile clouds, for example with control of the angle of thenozzle, by a person of ordinary skill on the art based on the teachingsprovided herein. In many embodiments, the nozzle of the fluid deliveryelement comprises a cavitating jet in order to improve ablation oftissue.

The fluid delivery element nozzle and pressure can be arranged toprovide a shedding frequency suitable for removal of tissue. The fluiddelivery element can be located on the probe at a distance from thetissue as described herein in order to provide improved tissueresection.

In many embodiments, the “white cloud” of “flame” comprises an“entrainment” region where surrounding water is drawn in or “entrained”into the jet. Work in relation to embodiments suggests that theentrainment of fluid can be related to the shedding frequency.

The shedding frequency and size of the cloud shed from the jet can beused to provide tissue ablation in accordance with embodiments. Theshedding frequency can be combined with the angular sweep rate of theprobe around the longitudinal axis to provide overlap of the locationswhere each cloud interacts with the tissue.

The shedding pulses as described herein can be beneficially combinedwith the scanning of the jet as described herein.

FIG. 4 shows a plurality of shedding pulses 995 and sweeping of theablative jet to provide smooth and controlled tissue erosion at aplurality of overlapping locations 997 in accordance with embodiments.This shedding frequency can be substantially faster than the pumpfrequency, when a pump is used, such that a plurality of shedding cloudsare provided for each pulse of the pulsatile pump. The sweep rate of theprobe can be related to shedding frequency to provide improved tissueremoval, for example with the shedding clouds configured to provideoverlapping pulses.

In many embodiments, the system comprises a pump having a frequency lessthan a frequency of the shedding pulses, in order to provide a pluralityof shedding pulses for each pulse of the pump. The pump can have a pulserate of at least about 50 Hz, for example within a range of about 50 Hzto about 200 Hz, and the shedding pulses comprise a frequency of atleast about 500 Hz, for example within a range from about 1 kHz to about10 kHz.

Although pulses of a pump are illustrated, similar scanning of pulsedclouds can be provided with a continuous flow pump.

While the nozzle can be configured in one or more of many ways, in manyembodiments the nozzle comprises a Strouhal number (hereinafter “St”)within a range from about 0.02 to about 0.3, for example within a rangefrom about 0.10 to about 0.25, and in many embodiments within a rangefrom about 0.14 to about 0.2.

In many embodiments, the Strouhal number is defined by:

St=(Fshed)*(W)/U

where Fshed is the shedding frequency, W is the width or diameter of thecavitating jet, and U is the velocity of the jet at the exit. A personof ordinary skill in the art can modify nozzles as described herein inorder to obtain shedding frequencies suitable for combination inaccordance with embodiments described herein, and experiments can beconducted to determine the cloud lengths and shedding frequenciessuitable for tissue removal.

The nozzle configurations providing plurality of shedding clouds aresuitable for use with one or more of the treatment probes as describedherein.

Cavitation

Cavitation is a phenomenon that occurs when a high-pressure waterjetshoots through a nozzle into a liquid medium. Localized vapor pocketsform as nuclei containing minute amounts of vapor and/or gas destabilizeas they are subjected to drops in pressure rather than the commonlyknown method of addition of heat. Cavitation occurs when the localpressure drops below the vapor pressure, which occurs when the negativepressure coefficient (−Cp) is greater than cavitation number (a),respectively governed by the equations below

$\begin{matrix}{{- C_{p}} = \frac{p_{ref} - p}{\frac{1}{2}\rho \; v_{ref}^{2}}} & (1) \\{\sigma = \frac{p_{ref} - p_{v}}{\frac{1}{2}\rho \; v_{ref}^{2}}} & (2)\end{matrix}$

where p_(ref) is the hydrostatic pressure at the nozzle depth, p is thelocal pressure at the jet, ρ is the fluid density, v_(ref) is the exitvelocity of the waterjet at the nozzle, and p_(v) is the vapor pressure.When a liquid flows through a constricted region, its velocity increasesto maintain continuity and there is a corresponding drop in pressure,known as the Venturi effect. Applying this to submerged waterjets, thevelocity of water exiting through a nozzle is increased dramatically dueto the constriction while the pressure of the jet stream issubstantially reduced. When the pressure reduction is significantenough, it can drop below the vapor pressure, resulting in vapor cavityformation.

For a given flow dynamic, a cavitation number 6 exists above whichcavitation does not occur and below which cavitation will be presentwith increased cavitating region size. Several smaller pockets cancombine to form a larger vapor cavity. As the momentum of the waterjetcarries the vapor cloud further away from the nozzle into surroundingmedium, viscous forces cause the jet velocity to drop and there is acorresponding rise in pressure. This rise causes the vapor cavity tocollapse, resulting in a pressure pulse which further accelerates nearbywater and causes localized microjets to form. Both the liquid microjetsand pressure pulse can exceed the damage threshold energy of a materialand cause erosion. Due to the rapid loss in velocity as the jet movesaway from the nozzle, beyond a given distance the kinetic energy of thestream no longer exceeds the threshold energy and pressure waves andmicrojets from collapsed cavitation clouds becomes the primary modalityfor erosion.

In many embodiments, cavitation is dependent on local changes inpressure only, making it an isothermal phenomenon, meaning no thermalfluctuations are expected. Experimentally, as the vapor cavitation growsin size, latent heat is drawn from the surrounding liquid, and a verysmall drop in temperature (˜0.35° C.) can be observed. Although in manyembodiments, the process is not entirely isothermal, the almostnegligible change in temperature is why waterjet cutting is useful formachining sensitive parts that demand no heat-affected zones.

In many embodiments, pressure pulse and microjet erosion becoming theprimary modality of material removal is the limited erosion radius.Since cavitation occurs due to the pressure differential of the waterjetrelative to the ambient liquid pressure, vapor cavities can only existup to a maximum distance before the cavity collapses as the jet slowsdown and the pressure comes to equilibrium with the surrounding liquid.As a result, submerged waterjet cutting becomes substantiallyself-limiting due to the range of pressure pulses and microjets beforethey dissipate and is a very safe and high precision tool to cut with.In alternative embodiments, a gaseous waterjet will have high kineticenergy levels that exceed the threshold energy at much longer distancessince there are relatively minimal forces acting on the jet to slow itdown.

FIG. 5 shows maximum tissue penetration depth of cutting and flow ratethrough a nozzle in accordance with embodiments. The maximum penetrationdepth corresponds substantially to the length of the cavitation bubblesof the jet comprising the “cold” aquablation flame. The maximum tissuepenetration depth of ablation corresponds directly to the flow rate andin many embodiments is linearly related to the flow rate.

The flame with cavitations is shown with 10 flow settings correspondingto flow rates within a range from about 50 ml/min to about 250 ml/minwith a nozzle and rotating probe as described herein. The maximumpenetration depth ranges from about 4 mm at 50 ml/min to about 20 mm at250 ml/min.

The inset of FIG. 5 shows cut potato as a model of prostate BPH, inaccordance with embodiments. The maximum penetration depth of potatocorresponds closely to the maximum cut depth of BPH. The potato is showncut with 6 flow settings corresponding to flow rates within a range fromabout 50 ml/min to about 250 ml/min with a nozzle and rotating probe asdescribed herein. The maximum penetration depth ranges from about 4 mmat 50 ml/min to about 20 mm at 250 ml/min, consistent with the images ofthe cavitations of the jet comprising the cool “flame” as describedherein.

In many embodiments, the cavitation cloud growth and length comprise afunction of flow rate, which is proportional to the injection pressureand vice versa, for an appropriately configured nozzle as describedherein. As the pressure increases, the maximum erosive radius appears toincrease linearly, which is shown as the maximum penetration depth ofFIG. 5.

High velocity cavitating jets can be created by using a knownhigh-pressure pump to force the water through a nozzle in either acontinuous or pulsatile flow. Despite the flow type produced by a pump,the cavitation phenomenon will be pulsatile due to the unsteady natureof vapor cavities and the cavity formation will be pulsatile even in acontinuous flow jet as described herein. Without being bound to aparticular theory, it is believed that both pulsatile and continuousflow waterjets will result in equivalent amounts of material erosionover a given amount of time. In many embodiments, nozzle geometry isconfigured to provide the flow dynamics and cavitation process asdescribed herein. In many embodiments, the nozzle is configured toinhibit tight constriction at the waterjet exit, which can be relatedcavitation can occur inside the nozzle itself. In many embodiments, thesharp corners cause the water to separate from the wall and convergetowards the nozzle centerline, further constricting the waterjet pathwaywhile simultaneously reducing frictional effects caused by the nozzlewall. This results in an increased velocity along with the correspondingpressure drop and the vapor cavities formation. Vapor cavity formationwill impact the overall flow dynamics as their eventual collapse resultsin turbulence and can affect erosion depth. A person of ordinary skillin the art can conduct experiments to determine appropriate nozzlegeometry and flow rate to provide tissue removal as described hereinwithout undue experimentation.

Aquablation

Submerged waterjet cutting as described herein has the capability totake advantage of the cavitation phenomenon to treat patients withBenign Prostatic Hyperplasia (BPH). The jet removes the excess softtissue growth seen in BPH through the pressure pulses and microjetscaused by collapsed vapor cavities. The waterjet direction can bemanipulated by changing the location and orientation of the devicesnozzle in one or more of many ways. For example, by one or more oftranslating the nozzle along the anterior-posterior direction or byrotating the nozzle up to an angle such as 180 degrees, for example, andcombinations thereof. As the handpiece probe may sit on the anteriorside of the prostate, a rotation angle can be used for ablating thetissue obstruction.

As vapor cavity formation and its erosive strength is a function of bothinjection pressure and the flow dynamics, the depth of material can becontrolled by configuring the pressure as well as nozzle geometry. Agreater injection pressure can result in a faster exit velocity. Asdescribed herein, the nozzle geometry can further increase the velocitydepending on the constriction and will affect the degree of pressuredrop as the waterjet exits through the Venturi effect. These factors canresult in longer distances the cavitation clouds can grow to and travelbefore collapsing and releasing pressure pulses and microjets. Thenozzle geometry and pressure settings of the Aquablation system havebeen optimized to give the user precise control and ensure thecavitating jet removes only the desired benign tissue growth.

The images provided herein show the how tissue erosion depth is afunction of pressure, in accordance with embodiments. The images showthe smaller cavitation cloud length and corresponding tissue resectiondepth for a lower injection pressure as compared with other images.

In many embodiments, Aquablation as described herein is capable ofremoving the excess tissue growth, e.g. BPH, with substantial removaland damage of arteries and veins and inhibited bleeding. In manyembodiments, the jet is positioned to provide cavitation energy abovethe threshold of both growth tissue such as BPH and collagenous tissuesuch as blood vessels, with decreased bleeding. The pressure pulses andmicrojets provided by cavitation exceed the threshold energy required toerode the soft tissue growth and the other structures like vessels whichhave a much higher threshold energy.

In many embodiments, generation of harmful emboli are inhibited. Vaporcavity formation may benefit from a minute nucleus of air alreadypresent in the blood stream, for example. Cavitation can result in thegrowth of the nucleus without any additional air being introduced intothe system. Furthermore, the cavity will collapse once the local jetpressure exceeds the vapor pressure, such that the air pockets mayreduce back to their original nucleus size. In many embodiments, embolusformation is inhibited as cavitation depends on and can be limited tomicro amounts of air native to the saline solution surrounding theurethra, and the vapor cavities quickly dissipate as the jet pressurebegins to rise.

FIG. 6 shows maximum tissue penetration 110 versus flow rate similar toFIG. 5 in accordance with embodiments. The nozzle positions in relationto tissue can be used to determine the tissue incision as substantiallyabrasive, or substantially selective, and combinations thereof, forexample. Selective tissue removal 105 of substantially non-collagenoustissue such as BPH at rates substantially faster than collagenous tissuesuch as vessels can be provided at distances beyond a transitionthreshold 109. Highly abrasive substantially non-selective removal 107can be provided at distances from tissue less than the thresholddistance 109, for example. The transition threshold may comprise asubstantially linear function with an offset. For example, the slope canbe somewhat steeper than the transition threshold with an offset.

The threshold transition from selective tissue removal to highlyabrasive substantially non-selective tissue removal may comprise one ormore of many functions of flow rate and distance from the nozzle. Forexample, the threshold transition may comprise one or more of a linearfunction, a polynomial function, or an empirically determined transformfunction, and combinations thereof, for example. A person of ordinaryskill in the art can determine the distances for selective removal andsubstantially abrasive tissue removal in accordance with the teachingsas described herein without undue experimentation.

FIG. 7 shows a threshold 109 transition from selective removal 105 toabrasive removal 107 comprising a slope similar to the slope of themaximum penetration depth 110, with an offset in accordance withembodiments. The offset can be related to the fluid jet parameters asdescribed herein.

FIGS. 8A and 8B show selective tissue removal, in accordance withembodiments. The tissue can be positioned at a distance greater than thetransition threshold in order to provide selective tissue removal. FIG.8A shows tissue T prior to selective removal. The soft granular tissueGT can be substantially removed with inhibited removal of collagenoustissue CT such as blood vessels V, as shown in FIG. 8B. Work in relationto embodiments suggests that the shedding pulses as described herein canaffect the endothelium, which may contribute to clotting and decreasedbleeding in accordance with some embodiments.

FIGS. 9A and 9B show highly abrasive tissue removal in accordance withembodiments. FIG. 9A shows tissue T prior to removal. FIG. 9B shows thetissue subsequent to removal. The collagenous tissue CT comprising theblood vessel V can be removed at substantially the same rate as thesubstantially less collagenous granular tissue GT such as BPH, as shownwith the removal profile RP. The highly abrasive tissue removal can beprovided with the nozzle positioned at a distance less than thetransition threshold for a provided flow rate as described herein.

In many embodiments, the endothelial cell lining E of the blood vesselsV can be affected so as to provide one or more of micro clotting;clotting; emboli or micro-emboli, and one or more biological responsesas described herein. In many embodiments, induced micro-clotting C cansubstantially occlude the blood vessels and capillaries of the occludedtissue.

FIG. 10 shows a collapsed vessel wall CW, in accordance withembodiments. The collapsed vessel wall CW can be generated with thehighly abrasive cavitation as described herein. In many embodiments, thecavitation and jet can induce collapse of the vessel wall W. Thecollapse of the vessel wall can inhibit blood flow through the incisedend of the vessel V.

The vessel wall can inhibit blood flow in one or more of many ways inresponse to the cavitation. In many embodiments, the ends of the cutvessel may comprise strands of cut collagen that provide an increasedsurface area to provide interaction with platelets and blood cells toinduce clotting. The frayed ends of the blood vessel can extend inwardlytoward to the end of the severed blood vessel so as to inhibit bleeding,for example. Alternatively or in combination, the endothelium of theblood vessel can be affected so as to provide clotting within thevessel.

FIG. 11A shows a water jet flame 101 removing tissue with sheddingpulses in accordance with embodiments. In many embodiments, the watershedding pulses induce a shear wave 121 along the lumen of the bloodvessel V. The plurality shedding pulses as described herein can provideoscillations of the liquid within the blood vessel. In many embodiments,the oscillations provide a shear wave propagating transverse to thevessel wall W at a distance from the tissue region where the flamestrikes. This shear wave can induce coagulation at a distance from theregion contacted with the cavitation 103 as shown in FIG. 11A. Thedisruption of the vessel at a distance from the jet may comprise one ormore of shearing of the endothelial layer E of the vessel, lysis of aplurality of endothelial cells at a distance, shearing of a plurality ofred blood cells RBC, lysis of the plurality of red blood cells shearingof platelets, partial removal of endothelial cells from the vascularwall, complete removal of endothelial cells, generation of fibrin orclotting, and combinations thereof, for example.

In many embodiments, the plurality of shedding pulses comprises at leastabout two shedding pulses for each pulse of the pump, for example withina range from about 5 to about 20 shedding pulses per pulse of the pump.The shedding pulses may comprise highly abrasive shedding pulses asdescribed herein, or selective shedding pulses as described herein, andcombinations thereof for example.

Work in relation to embodiments suggests that the substantially abrasivezone of the jet comprising shedding pulses can be effective in providingthe increased clotting as described herein. Alternatively or incombination, the selective tissue removal zone can be effective inproviding the increased clotting as described herein.

FIG. 11B shows disruption 123 to a blood vessel V in accordance withembodiments. The disruption of the endothelium E and correspondingclotting C as described herein are shown at a distance 125 from thetissue removal profile RP.

While preferred embodiments of the present disclosure have been shownand described herein, it will be obvious to those skilled in the artthat such embodiments are provided by way of example only. Numerousvariations, changes, and substitutions will be apparent to those skilledin the art without departing from the scope of the present disclosure.It should be understood that various alternatives to the embodiments ofthe present disclosure described herein may be employed withoutdeparting from the scope of the present invention. Therefore, the scopeof the present invention shall be defined solely by the scope of theappended claims and the equivalents thereof

What is claimed is:
 1. An apparatus to ablate vascular tissue, theapparatus comprising, a pump; a nozzle coupled to the pump, the nozzlesized for immersion in a liquid; circuitry coupled to the pump and thenozzle, the circuitry configured to provide a plurality of sheddingpulses with a jet released into the liquid.
 2. The apparatus of claim 1,wherein the pump provides a flow rate and the nozzle is configured toprovide a plurality of shedding pulses in order to provide a pulsatileshear wave extending a distance from a cut profile to an affectedlocation of a blood vessel, and wherein the affected location promotesblood clotting.
 3. The apparatus of claim 1, wherein the nozzle isarranged with the tissue at a distance no more than a thresholdtransition distance from the tissue.
 4. The apparatus of claim 1,wherein the nozzle is arranged with the tissue at a distance greaterthan a threshold transition distance from the tissue.
 5. The apparatusof claim 1, further comprising a processor comprising instructions totreat the vascular tissue with the nozzle, the processor coupled to alinkage to move the nozzle in response to the instructions, wherein theprocessor comprises instructions to remove the tissue with a tissueremoval profile with the nozzle positioned at a distance no more than athreshold transition distance for selective tissue removal from thetissue removal profile.
 6. The apparatus of claim 1, wherein the pumpcomprises a piston to deliver a plurality of pump pulses and wherein thenozzle and a flow rate of the pump are configured to provide a pluralityof pump pulses and each of the plurality of pump pulses provides aplurality of shedding pulses.
 7. The apparatus of claim 1, furthercomprising a processor comprising instructions to treat the vasculartissue with the nozzle, the processor coupled to a linkage to move thenozzle in response to the instructions, wherein the processor comprisesinstructions to remove the tissue with a tissue removal profile with thenozzle positioned at a distance no more than a threshold transitiondistance from the tissue removal provide for selective tissue removal.8. The apparatus of claim 1, wherein the jet is arranged to be directedtoward tissue to be cut, wherein jet hydrodynamic parameters areconfigured to allow mechanical disruption of the tissue, and wherein thejet hydrodynamic parameters are also configured to inhibit bleeding. 9.The apparatus of claim 8, wherein the jet hydrodynamic parameterscomprise one or more of a fluid jet velocity or a shear stress field,and/or wherein the jet hydrodynamic parameters are configured to controla cavitation field in order to cut the tissue with inhibited bleeding.10. The apparatus of claim 1, wherein the nozzle is configured toprovide the jet and is directed toward the vascularized tissue in theliquid to cut said tissue through mechanical interaction of the jet withthe tissue, wherein bleeding of cut vessels within the tissue isinhibited by one or more of platelet aggregation or thrombus formationin response to one or more hydrodynamic parameters of the jet.
 11. Theapparatus of claim 1, wherein the shedding pulses provide a pulsatileshear wave extending a distance from a tissue removal profile to anaffected location of a blood vessel, and wherein the shear wave promoteshemostasis at the affected location.
 12. The apparatus of claim 1,wherein the jet comprises a substantially abrasive jet in order toremove vessels and non-vascular tissue of the vascular tissue at similarrates, and/or wherein the plurality of shedding pulses comprisessubstantially abrasive shedding pulses in order to remove vessels andnon-vascular tissue of the vascular tissue at similar rates.
 13. Theapparatus of claim 1, wherein the vascular tissue is removed with aremoval profile and the bleeding is inhibited at a distance from theremoval profile.
 14. The apparatus of claim 13, wherein bleeding of thevascular tissue is inhibited with one or more of induced thrombosis incapillaries and arterioles related to endothelial injury, shear stressand reduction in blood flow, adhesion and aggregation of platelets,deposition of fibrin; deposition of fibrin related to obstructive vesselclotting, fluid pressure in an affected zone; fluid pressure in anaffected zone at a distance from a removal profile, inhibited blood flowin the affected vessels, partial collapse of the affected blood vessels,or full collapse of the affected blood vessels.